fever projr malaria 21/M
malaria -
date of admission 3/12/2022
date of discharge 12/12/22
Diagnosis
ACUTE FEBRILE ILLNESS (? CLINICAL MALARIA) WITH PAN GASTRITIS
Case History and Clinical Findings
PATIENT WAS AOPPARENTLY ASSYMTOMATIC 5DAYS BACK AND DEVELOPED HIGH GRADE FEVER,CONTINOUS TYPE ASSOCIATED WITH CHILLS AND RIGORS WHICH RELIEVED ON MEDICATION,H/O VOMITINGS SINCE 5DAYS ,DAILY 4 EPISODES NON PROJECTILE ,WATERY IN CONSISTENCY
H/O COUGH SINCE 5DAYS ,NON PROJECTILE ,H/O HEADACHE + SINCE 5DAYS ON AND OFF ,SUDDEN IN ONSET ,NO H/O BURNING MICTURITION,NO H/O LOOSE STOOLS
NOT A K/C/O DM, HTN, ASTHMA, CAD
O/E-
PATIENT IS C/C/C
TEMP- 101 F
PR- 102BPM
RR- 16 CPM
BP- 110/80MMHG
SPO2- 97% ON RA
GRBS- 162MG%
CVS- S1S2+
RS- BAE+, NVBS
P/A- SOFT, NON TENDER, BOWEL SOUNDS +
CNS- NAD
Treatment Given(Enter only Generic Name)
DAY1-
1)NBM
2)INJ.PAN 80MG IN 100ML NS OVER 1HR IV/STAT
3)IVF:2 NS
2 RL @ 75ML/HR
4)INJ.NEOMOL 1GM IV/SOS(IF TEMP >101F)
5)T.DOLO 650MG/PO/TID
DAY 2:
1)NBM
2)INJ.PAN 80MG IN 100ML NS OVER 1HR IV/STAT
3)IVF:2 NS
2 RL @ 75ML/HR
4)INJ.NEOMOL 1GM IV/SOS(IF TEMP >101F)
5)T.DOLO 650MG/PO/TID
DAY 3:
1)NBM
2)INJ.ZOFER 4MG IV/TID
3)IVF:2 NS
2 RL @ 75ML/HR
4)INJ.NEOMOL 1GM IV/SOS(IF TEMP >101F)
5)T.DOLO 650MG/PO/TID
6)INJ.METROGYL 500MG/IV/BD
7)TAB.DOXY 100MG PO/BD
DAY4:
1)NBM
2)INJ.ZOFER 4MG IV/TID
3)IVF:2 NS
2 RL @ 75ML/HR
4)INJ.NEOMOL 1GM IV/SOS(IF TEMP >101F)
5)T.DOLO 650MG/PO/TID
6)INJ.METROGYL 500MG/IV/BD
7)CHLORHEIDINE MOUTH GARGLING TWICEDAILY
8)TAB.DOXY 100MG PO/BD
DAY5:
1)NBM
2)INJ.ZOFER 4MG IV/TID
3)IVF:2 NS
2 RL @ 75ML/HR
4)TAB.AZITHRO 500MG PO/OD
5)TAB.DOXY 100MG PO/BD
6)INJ.NEOMOL 1GM IV/SOS(IF TEMP >101F)
7)T.DOLO 650MG/PO/TID
8)CHLORHEIDINE MOUTH GARGLING TWICEDAILY
DAY 6:
1)NBM
2)INJ.ZOFER 4MG IV/TID
3)IVF:2 NS
2 RL @ 75ML/HR
4)TAB.AZITHRO 500MG PO/OD
5)TAB.DOXY 100MG PO/BD
6)INJ.NEOMOL 1GM IV/SOS(IF TEMP >101F)
7)T.DOLO 650MG/PO/TID
8)CHLORHEIDINE MOUTH GARGLING TWICEDAILY
DAY7:
1)NBM
2)INJ.ZOFER 4MG IV/TID
3)IVF:2 NS
2 RL @ 75ML/H
4)TAB.AZITHRO 500MG PO/OD
5)TAB.DOXY 100MG PO/BD
6)INJ.NEOMOL 1GM IV/SOS(IF TEMP >101F)
7)T.DOLO 650MG/PO/TID
8)CHLORHEIDINE MOUTH GARGLING TWICEDAILY
DAY 8:
1)NBM
2)INJ.ZOFER 4MG IV/TID
3)IVF:2 NS
2 RL @ 75ML/HR
4)TAB.AZITHRO 500MG PO/OD
5)TAB.DOXY 100MG PO/BD
6)INJ.NEOMOL 1GM IV/SOS(IF TEMP >101F)
7)T.DOLO 650MG/PO/TID
8)CHLORHEIDINE MOUTH GARGLING TWICEDAILY
DAY9:
1)NBM
2)INJ.ZOFER 4MG IV/TID
3)IVF:2 NS
2 RL @ 75ML/HR
4)TAB.AZITHRO 500MG PO/OD
5)TAB.DOXY 100MG PO/BD
6)INJ.NEOMOL 1GM IV/SOS(IF TEMP >101F)
7)T.DOLO 650MG/PO/TID
8)CHLORHEIDINE MOUTH GARGLING TWICEDAILY
DAY10(12/12/22):
1)IVF:2 NS
2 RL @ 75ML/HR
2)TAB.AZITHRO 500MG PO/OD
3)TAB.DOXY 100MG PO/BD
4)INJ.ZOFER 4MG IV/TID
5)INJ.NEOMOL 1GM IV/SOS(IF TEMP >101F)N
6)INJ ESOMEPRAZOLE 40MG IV/OD
7)T.DOLO 650MG/PO/TID
Advice at Discharge
1)TABPCM 650MG PO/SOS
2)TAB ZOFER 4MG PO/SOS
3)TAB.PAN 40MG PO/OD X 5DAYS
4)TAB.MVT PO/ODX7DAYS
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